3206-NEW PVQ Part C

Personnel Vetting Questionnaire

PVQ_Part C_Final_Sept_2023

Personnel Vetting Questionnaire

OMB: 3206-0279

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3206-0279 can be found here:

Document [docx]

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For Reference Only

Part C – Mandatory for all National Security Positions

Continuation of Section 09 - U.S. Military and U.S. Uniformed Service

[5] Branch Auto Populate for Affirmative Answer to Military Service or U.S. Uniformed Service, Disciplinary Actions\Court Martial and a Charge Outcome of Guilty. Sentence of Confinement. Details.

Were you sentenced to more than one year of imprisonment?

[] Yes

[] No

When were you imprisoned?

From (Month/Year)

[ mm/yyyy ]

[] Estimated

To (Month/Year)

[ mm/yyyy ]

[] Estimated

Were you granted parole or supervised release?

[] Yes

[] No

[6] Branch Auto Populate for Affirmative Answer to Military Service or U.S. Uniformed Service, Disciplinary Actions\Court Martial and a Charge Outcome of Guilty. Parole After Confinement

What are or were the dates of your parole or supervised release?

From (Month/Year)

[ mm/yyyy ]

[] Estimated

To (Month/Year)

[ mm/yyyy ]

[] Estimated

[] Present

Continuation of Section 23 – Financial Record

[1] Branch Auto Populate Affirmative Answer for Failed to Pay Non-Federal Taxes in the Past Five Years. Payment Status.

Have you since paid these taxes in full?	[] Yes	[] No

When did you pay these taxes in full?

[ mm/yyyy ]

[] Estimated

Shape1

[2] Branch Auto Populate Affirmative Answer for Failed to Pay Non-Federal Taxes in the Past Five Years. Filing Deadlines.

When was the filing date for these taxes?

[ mm/yyyy ]

When did you file these taxes?

[ mm/yyyy ]

[] Estimated

[2] Branch Auto Populate Affirmative Answer for Failed to Pay Non-Federal Taxes in the Past Five Years. Filing Information.

Did you file these taxes on time? (Answer "Yes" if you had an approved filing extension and filed by

the extension due date.)

[] Yes

[] No

Section 25 - Foreign Contacts

This section asks for information regarding any foreign nationals with whom you or your spouse, legally-recognized partner, or person with whom you are in a committed, spouse-like relationship have had contact in the past five years. (Only report information prior to your 18th birthday if necessary to report a minimum of 2 years of information.) Do not list your spouse; legally-recognized partner from a civil union, domestic partnership, or common law marriage; person you are in a committed, spouse-like relationship with; or relatives you've listed previously on this form.

For this section:

• A foreign national is any person who is not a citizen or national of the United States. A foreign national may live in the United States or another country. The United States is comprised of the 50 U.S. states, District of Columbia, and U.S. territories.

• Do not list dual U.S. citizens (a U.S. citizen who is a citizen of another country at the same time).

• Do not list foreign nationals with whom you only had contact while on official business for the U.S. Government.

• Do not list foreign nationals who you have previously listed on this form under the Relatives section.

• Report the information you currently know about the foreign national individual. Do not contact the foreign national to ask about information being collected on this form.

• Contact is defined as communication that is in person; by written correspondence, telephone, electronic media (e.g., email, text, social media, internet, etc.); or other method.

Have you had contact with a foreign national in the past five years with whom you:

• Had feelings of affection, or

• Had a romantic relationship, or

• Were bound by social, moral, financial, or legal obligations, or

• Shared information about yourself that, if known, could be used to influence you to act against the interests of the U.S. government.

(Answer "Yes" if one or more of the bulleted answers apply.)

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer on Contact with Foreign Nationals in Past Five years Who Meets One or More of Conditions Listed. Name of Foreign National.

What is the foreign national's name?

Last Name	[ Text ]	[] Letter(s) Only
		[] I Don't Know

First Name	[ Text ]	[] Letter(s) Only
		[] I Don't Know

Middle Name	[ Text ]	[] Letter(s) Only	[] No Middle Name
		[] I Don't Know

Suffix

[ Text ]

Has this foreign national ever used another name (for example, aliases, nicknames, or a maiden name)?

[] Yes

[] No

[] I Don’t Know

[2] Branch Auto Populate for Affirmative Answer on Contact with Foreign Nationals in Past Five years Who Meets One or More of Conditions Listed. Branch Auto Populate if the Foreign National Has Used Other Names.

What other name have they used?

[] I Don't Know

Last Name	[ Text ]	[] Letter(s) Only
		[] I Don't Know

First Name	[ Text ]	[] Letter(s) Only
		[] I Don't Know

Middle Name	[ Text ]	[] Letter(s) Only	[] No Middle Name
		[] I Don't Know

Suffix

[ Dropdown ]

Which of the following best describes this name?

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer on Contact with Foreign Nationals in Past Five years Who Meets One or More of Conditions Listed. Branch Auto Populate for Explanation if Selection of “Other” for Description of Name in Dropdown Menu.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in Past Five Years Who Meets One or More of Conditions Listed. Asking for Other Names Used by Foreign National.

Is there another name this foreign national uses or used (for example, aliases, nicknames, or a maiden name)?

[] Yes

[] No

[] I Don’t Know

[2] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the past five years Who Meets One or More of Conditions Listed. Citizenship Information.

Provide country(ies) of citizenship for this foreign national (Select all that apply.)

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the past five years Who Meets One or More of Conditions Listed. Date of Birth and Place of Birth Details.

What is their date of birth?

[ mm/yyyy ]

[] Estimated

[] I Don't Know

Where were they born?

[] I Don't Know

City

[ Text ]

[] I Don't Know

Country

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. And is a U.S. Born Foreign Citizen. Foreign Citizenship details.

How did this person become a citizen of a foreign country? (For example, they applied for it or they acquired it through their parents or grandparents.)

[ Text ]

[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer on Contact with Foreign Nationals in the Past Five Years Who Meets One or More of Conditions Listed. Residence Location.

Does this foreign national currently live in the U.S.?		[] Yes	[] No
		[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Resides in the U.S.

What is their address?

[] I Don't Know

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

[] I Don't Know

City

[ Text ]

[] I Don't Know

State or Territory	[ Dropdown ]
		[] I Don't Know

ZIP Code

[ Text ]

[] I Don't Know

Is this a U.S. military installation?		[] Yes	[] No
		[] I Don't Know

[4] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Resides in the U.S. in a Military Installation

What is the name of the U.S. military installation?

[ Text ]

[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Does Not Reside in the U.S.

Where do they live?

[] I Don't Know

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

[] I Don't Know

Country	[ Dropdown ]
		[] I Don't Know

Is this a U.S. military installation or U.S. diplomatic facility?		[] Yes	[] No
		[] I Don't Know

[4] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Does Not Reside in the U.S. and Resides in a U.S. Military Installation or U.S. Diplomatic Facility.

What is the name of the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] I Don't Know

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Type of Relationship with Foreign National.

What is your relationship with this person?

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Explanation for Selection of “Other” for Relationship Description in Dropdown Menu.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Additional Question on Span and Method of Contact.

When was your first contact with this foreign national?

[ mm/yyyy ]

[] Estimated

When was your last contact with this foreign national?

[ mm/yyyy ]

[] Estimated

What methods do you and this foreign national use to contact one another? (Select all that apply.)

What is the foreign national’s email address?

What is the foreign national’s phone number?

[ Dropdown ]

[Test]

[Text]

[] Cell []Home [] Work

[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. If Selection for Method of Contact in Dropdown Menu is “Other.”

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Frequency of Contact.

How often are you in contact with this foreign national?

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. If Selection for Frequency of Contact in Dropdown Menu is “Other.”

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Foreign National Employer Information.

Who does this foreign national work for? (If they are unemployed, provide the name of their most recent employer.)

[ Text ]

[] Never Worked

[] I Don't Know

If known, what is this foreign national’s occupation?

[Text]

[] I Don't Know

Is this employer located in the U.S.?

[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Employer Information Located in the U.S.

What is the employer's address?

[] I Don't Know

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

Is this a U.S. military installation?		[] Yes	[] No
		[] I Don't Know

[4] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. If Employer is in a U.S. and in Military Installation in the U.S.

What is the name of the U.S. military installation?

[ Text ]

[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. If Employer Address is in a U.S. Military Installation not in the U.S. Address.

Where is the employer located?

[] I Don't Know

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

[] I Don't Know

Country	[ Dropdown ]	[] I Don't Know

Is this a U.S. military installation or U.S. diplomatic facility?		[] Yes	[] No
		[] I Don't Know

[4] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Location Not in the U.S. but in Military Installation or Diplomatic Facility Abroad.

What is the name of the U.S. military installation or diplomatic facility?	[ Text ]	[] I Don't Know
		[] Not Applicable

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Foreign Government Affiliation Question.

Is this person associated with any of the following foreign disciplines? (Select all that apply)

[ Dropdown ]

[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Foreign Government Affiliation Selection of “Other” in dropdown menu.

Please explain.

[ Text ]

[3] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Foreign Government Affiliation Description.

Please describe this association.

[ Text ]

[] I Don't Know

[1] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Additional Questions

Does your relationship with this foreign national influence your actions or obligate you in any way, now or in the future?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed. Explanation for Affirmative Answer to Relationship Influences or Obligates Individual in Any Way Now or in the Future. Text field

Please explain.

[ Text ]

[1] Branch Auto Populate asking if there are any Other Instances of Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed.

Do you have another instance in which you've had contact with a foreign national in the past five years with whom you:

• Had feelings of affection, or

• Had a romantic relationship, or

• Were bound by social, moral, financial, or legal obligations, or

• Shared information about yourself that, if known, could be used to influence you to act against the interests of the U.S. government.

(Answer "Yes" if one or more of the bulleted answers apply.)

[] Yes

[] No

*** End Of Branch ***

Does your spouse; legally-recognized partner from a civil union, domestic partnership, common law marriage; or, the person with whom you are in a committed, spouse-like relationship have a foreign national contact that influences your actions or obligates you in any way, now or in the future?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligates Individual. Was Foreign National Already Listed on the Form.

Did you list this foreign national above?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that may Influence or Obligate Individual, Not Previously Listed.

What is the foreign national's name?

[] I Don't Know

Last Name	[ Text ]	[] Letter(s) Only
		[] I Don't Know

First Name	[ Text ]	[] Letter(s) Only
		[] I Don't Know

Middle Name	[ Text ]	[] Letter(s) Only	[] No Middle Name
		[] I Don't Know

Suffix

[ Text ]

Has this foreign national ever used another name (for example, aliases, nicknames, or a maiden name)?

[] Yes

[] I Don't Know

[] No

[3] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Other Names Used by Foreign National.

What other name have they used?

[] I Don't Know

Last Name	[ Text ]	[] Letter(s) Only
		[] I Don't Know

First Name	[ Text ]	[] Letter(s) Only
		[] I Don't Know

Middle Name	[ Text ]	[] Letter(s) Only	[] No Middle Name
		[] I Don't Know

Suffix

[ Dropdown ]

Which of the following best describes this name?

[ Dropdown ]

[4] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Explanation for selection or “Other” in Description of Name Dropdown menu.

Please explain.

[ Text ]

[3] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Additional Name.

Is there another name this foreign national uses or used (for example, aliases, nicknames, or a maiden name)?

[] Yes

[] I Don't Know

[] No

[3] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Citizenship Related Questions

Provide country(ies) of citizenship for this foreign national. (Select all that apply.)

[ Dropdown ]

[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Birth Details Questions.

What is their date of birth?

[ mm/yyyy ]

[] Estimated

[] I Don't Know

Where were they born?

[] I Don't Know

City

[ Text ]

[] I Don't Know

Country

[ Dropdown ]

[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Residence Location Question

Does this foreign national currently live in the U.S.?		[] Yes	[] No
		[] I Don't Know

[4] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Residence Location in the U.S.

What is their address?

[] I Don't Know

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

[] I Don't Know

City

[ Text ]

[] I Don't Know

State or Territory	[ Dropdown ]
		[] I Don't Know

ZIP Code

[ Text ]

[] I Don't Know

Is this a U.S. military installation?		[] Yes	[] No
		[] I Don't Know

[5] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Residence Location in the U.S. in Military Installation. Name.

What is the name of the U.S. military installation?

[ Text ]

[] I Don't Know

Where do they live?

[] I Don't Know

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

[] I Don't Know

Country	[ Dropdown ]
		[] I Don't Know

Is this a U.S. military installation or U.S. diplomatic facility?		[] Yes	[] No
		[] I Don't Know

[5] Branch Auto Populate for Affirmative Answer to Spouse Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Residence Location Not in the U.S. but in a Military Installation or Diplomatic Facility.

What is the name of the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] I Don't Know

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Spouse’s Relationship with Foreign National Question.

What is the relationship of this foreign national to your spouse, legally-recognized partner, or the person with whom you are in a committed, spouse-like relationship?

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Explanation for Selection of “Other” for Spouse Relationship with Foreign National in Dropdown Menu.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Individual’s Relationship with Foreign National Question.

What is your relationship with this foreign national?

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Explanation for Selection of “Other” in Dropdown Menu for Individual’s Relationship with Foreign National.

Please explain.

[ Text ]

When was your last contact with this foreign national?

[ mm/yyyy ]

[] Estimated

How often are you in contact with this foreign national?

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Explanation for Selection of “Other” in Dropdown Menu for Individual’s Relationship with Foreign National Frequency of Contact.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Association Question.

Is this person associated with any of the following foreign disciplines?

[ Dropdown ]

[] I Don't Know

Please explain.

[ Text ]

[3] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Affirmative Answer to Foreign National Associated with Foreign Disciplines.

Please describe this association.

[ Text ]

[3] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Text Field Explanation for Why the Foreign National May Influence or Obligate Individual.

Why do you feel the contact between this foreign national and your spouse, legally-recognized partner, or the person with whom you are in a committed, spouse-like relationship influences your actions or obligates you in any way, now or in the future?

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Another Instance to Report.

Do you have another instance in which your spouse; legally-recognized partner from a civil union, domestic partnership, common law marriage; or, the person with whom you are in a committed, spouse-like relationship has a foreign national contact that influences your actions or obligates you in any way, now or in the future?

[] Yes

[] No

*** End Of Branch ***

Section 26 - Foreign Financial Interests and Foreign Benefits

This section asks for information regarding any foreign financial interests or benefits you or your family members have or had in the past five years. Information requested includes what the foreign financial interests or benefits are, their value, and who controls them, as applicable.

For this section:

• Foreign means non-U.S. -- that is, any geographic location not within the 50 U.S. states, the District of Columbia, and the U.S. territories.

• A person has a foreign financial interest in a foreign account if the person is the owner or co-owner of record or has legal title. This applies whether the account is maintained for the person's own benefit or for the benefit of others. Examples of foreign financial interests include foreign (non-U.S.) stocks, bonds, property, investments, bank accounts, ownership of corporate entities, corporate interests or exchange traded funds (ETFs) held in specific geographical or economic sectors. Foreign financial interests do not include financial interests in companies or diversified mutual funds or diversified ETFs that are publicly traded on a U.S. exchange.

• A dependent child is an unmarried child, stepchild, legally adopted child or foster child, or child of a domestic partner who is: 1) younger than 19 years old, 2) at least 19 but less than age 24 years old and who regularly attends an accredited school or college, or 3) permanently and totally disabled -- and, in all 3 cases is primarily dependent on you for support and maintenance.

• For purposes of this form a committed, spouse-like relationship is defined as a relationship between two people who are not in a legally-recognized marriage, union, or domestic partnership, present themselves as a couple, and live together continuously.

Have you or any of the people listed below owned a foreign financial interest in the past five years?

• Spouse or legally recognized partner from a civil marriage, civil union, domestic partnership, or common law marriage

• Person with whom you are in a committed, spouse-like relationship

• Dependent child

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years.

Who owns or owned a foreign financial interest in the past five years? (If more than one person owns or owned the financial interest select one. You will be given the opportunity to add co-owners.)

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Owned by Dependent Child.

What is the name of the dependent child?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Co-Owner.

Are there or were there any co-owners for this foreign financial interest?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Identity of Co-Owner.

Who is or was the co-owner?

[ Dropdown ]

[4] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Explanation for Selection of “Other” for Identity of Co-Owner Dropdown Menu.

Please explain.

[ Text ]

[4] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Branch Auto Populate for Co-Owner with Another Individual Not Individual, Spouse, Spouse-like, or Dependent Child. Information on Co-Owner.

What is or was your relationship to this co-owner?

[ Text ]

[] None

What is the name of the co-owner?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

[5] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Citizenship of Co-Owner.

Provide country(ies) of citizenship for this co-owner. (Select all that apply.)	[ Dropdown ]
		[] I Don't Know

[4] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Co-Owner Live in the U.S.

Does this co-owner currently live in the U.S.?		[] Yes	[] No
		[] I Don't Know

[5] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Co-Owner Address.

What is their address?

[] I Don't Know

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

[] I Don't Know

City

[ Text ]

[] I Don't Know

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[] I Don't Know

Is this a U.S. military installation?		[] Yes	[] No
		[] I Don't Know

[6] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Co-Owner on Military Installation.

What is the name of the U.S. military installation?

[ Text ]

[] I Don't Know

[5] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Co-Owner Does Not Live in the U.S.

Where do they live?

[] I Don't Know

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

[] I Don't Know

Country

[ Dropdown ]

Is this a U.S. military installation or U.S. diplomatic facility?		[] Yes	[] No
		[] I Don't Know

[6] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Co-Owner Not in the U.S. but on U.S. Military Installation or U.S. Diplomatic Facility.

What is the name of the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] Not Applicable (Text)

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Another Co-Owner for Financial Interest.

Do you have another co-owner for this foreign financial interest to report?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Type of Foreign Financial Interest.

What is the foreign financial interest you or the person(s) you listed above own or owned? (Check one. There will be an opportunity to input multiple entries.)

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Explanation for Selection of “Other” for Type of Foreign Financial Interest in Dropdown Menu.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Foreign Financial Interest is Real Estate. Type of Real Estate.

What type of real estate is this?

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Explanation for Selection of “Other” for Type of Real Estate in Dropdown Menu.

Please explain.

[ Text ]

Where is this real estate located?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

Country

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Foreign Financial Interest is Real Estate. Acquisition Details.

When was this real estate acquired?

[ mm/yyyy ]

[] Estimated

How was this real estate acquired?

[ Dropdown ]

[4] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Foreign Financial Interest is Real Estate. Explanation for Selection of “Other” on dropdown menu for How Real Estate Acquired.

Please explain.

[ Text ]

How much did you or the person(s) you listed above pay for this real estate (in U.S. dollars)?

[ Text ]

Do you or the person(s) you named above own this real estate today?

[] Yes

[] No

What is the current value of this real estate (in U.S. dollars)?

[ Text ]

What was the value of this real estate when it was sold or otherwise relinquished?

[ Text ]

When was this real estate sold or otherwise relinquished?

[ mm/yyyy ]

[] Estimated

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Foreign Interest is Financial. Location.

Which foreign country is or was this foreign financial interest associated with?

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Acquisition Details.

When was this foreign financial interest acquired?

[ mm/yyyy ]

[] Estimated

How was this foreign financial interest acquired?

[ Dropdown ]

Please explain.

[ Text ]

[4] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Purchase Price.

How much did you or the person(s) you listed above pay for this foreign financial interest (in U.S. dollars)?

[ Text ]

[3] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Current Ownership.

Do you or the person(s) you named above own this financial interest today?

[] Yes

[] No

[4] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Current Value.

What is the current value of this foreign financial interest (in U.S. dollars)?

[ Text ]

[4] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Value when Sold or Relinquished.

What was the value of this foreign financial interest when it was sold, lost, or otherwise relinquished (in U.S. dollars)?

[ Text ]

How was this financial interest relinquished?

[ Dropdown ]

[5] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Explanation for Selection of “Other” in Dropdown Menu for How Interest Relinquished.

Please explain.

[ Text ]

[4] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Date Sold or Relinquished.

When was this foreign financial interest relinquished?

[ mm/yyyy ]

[] Estimated

[3] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Anyone Else Controls the Foreign Financial Interest.

Does or did a company, organization, or person (other than the owner or co-owner) control this foreign financial interest on behalf of the owner or co-owner? (Select the applicable box.)

[ Dropdown ]

Please explain.

[ Text ]

[4] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Name of Company / Organization Controlling Foreign Financial Interest.

What is the name of the company or organization that controlled this foreign financial interest on behalf of the owner or co-owner?

[ Text ]

[4] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Selection of Controlled by Another Person. Relationship of Person with Owner or Co-Owner

What is the relationship of the person who controls this foreign financial interest to the owner or co-owner of this financial interest?

[ Dropdown ]

[5] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Selection of Controlled by Another Person. Explanation for Selection of “Other” Type of Relationship of Person with Owner or Co-Owner.

Please explain.

[ Text ]

[] None

What is the name of the person who controls the foreign financial interest?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

[6] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Selection of Controlled by Another Person. Citizenship.

Provide country(ies) of citizenship for this person. (Select all that apply.)	[ Dropdown ]
		[] I Don't Know

Does this person currently live in the U.S.?		[] Yes	[] No
		[] I Don't Know

What is their address?

[] I Don't Know

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

[] I Don't Know

City

[ Text ]

[] I Don't Know

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[] I Don't Know

Is this a U.S. military installation?		[] Yes	[] No
		[] I Don't Know

[7] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Selection of Controlled by Another Person. Lives in U.S. on a Military Installation. Name.

What is the name of the U.S. military installation?

[ Text ]

[] Not Applicable (Text)

Where do they live?

[] I Don't Know

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

[] I Don't Know

Country

[ Dropdown ]

Is this a U.S. military installation or U.S. diplomatic facility?		[] Yes	[] No
		[] I Don't Know

What is the name of the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] Not Applicable (Text)

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] I Don't Know

[4] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Foreign Financial Interest Controlled by Another Person, Organization or Company.

Is there or was there another company, organization, or person (other than the owner or co-owner) that controlled this foreign financial interest on behalf of the owner or co-owner? (Select the applicable box.)

[] Yes

[] No

[5] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Explanation for Control by Another Person, Organization or Company.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Another Instance to Report.

Do you have another instance in which you or any of the people listed below owned a foreign financial interest in the last five years?

• Spouse or legally recognized partner from a civil marriage, civil union, domestic partnership, or common law marriage

• Person with whom you are in a committed, spouse-like relationship

• Dependent child

[] Yes

[] No

*** End Of Branch ***

Do you control (not own) a foreign financial interest on someone else's behalf?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Individual Controlling Foreign Financial Interest of Others. Name and Relationship.

Who do you control a foreign financial interest for?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]	[] None

What is your relationship with this person?	[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Foreign Financial Interest

What is the foreign financial interest?

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Individual Controlling Foreign Financial Interest of Others. Explanation for Selection of “Other” in dropdown menu for Type of Foreign Financial Interest.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Individual Controlling Foreign Financial Interest of Others. Value.

What is the value of this foreign financial interest?

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Individual Controlling Foreign Financial Interest of Others. Country.

What country is this foreign financial interest associated with?

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Individual Controlling Foreign Financial Interest of Others. Additional Questions.

Why do you control this foreign financial interest for this person?

[ Text ]

Do you have another instance in which you control (not own) a foreign financial interest on someone else's behalf?

[] Yes

[] No

*** End Of Branch ***

Do you or any of the people listed below expect to own any foreign financial interests in the future?

• Spouse or legally recognized partner from a civil marriage, civil union, domestic partnership, or common law marriage

• Person with whom you are in a committed, spouse-like relationship

• Dependent child

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Expects Future Foreign Financial Interest. Who is Expected to Own.

Who expects to own a foreign financial interest in the future?

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Expects Future Foreign Financial Interest. Future Ownership by Dependent Child.

What is the name of the dependent child?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]	[] None

[1] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Expects Future Foreign Financial Interest. Type of Foreign Financial Interest.

What is the foreign financial interest?

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Expects Future Foreign Financial Interest. Explanation for Selection of “Other” for Type of Foreign Financial Interest.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Expects Future Foreign Financial Interest. Additional Details Questions. Another Instance to Report.

What country is this financial interest associated with?

[ Dropdown ]

When do you or the person you listed above expect to receive this future foreign financial interest?

[ mm/yyyy ]

[] Estimated

Why do you or the person you listed above expect to receive this future foreign financial interest?

[ Text ]

Do you have another instance in which you or any of the people listed below expect to own a foreign financial interest in the future?

• Spouse or legally recognized partner from a civil marriage, civil union, domestic partnership, or common law marriage

• Person with whom you are in a committed, spouse-like relationship

• Dependent child

[] Yes

[] No

*** End Of Branch ***

Have you or any of the people listed below received any educational, medical, retirement, social welfare, or other such benefits from a foreign country in the past five years?

• Spouse or legally recognized partner from a civil marriage, civil union, domestic partnership, or common law marriage

• Person with whom you are in a committed, spouse-like relationship

• Dependent child

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years. Who Receives the Benefits.

Who received this benefit? (If more than one of the people listed received a benefit select one. There will be an opportunity to input multiple entries.)

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years. Benefit Received by Dependent Child. Name.

What is the name of the dependent child?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]	[] None

[1] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years. Type of Benefit.

What type of benefit was received? (If more than one, select one. There will be an opportunity to input multiple entries.)

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years. Explanation for Selection of “Other” in Dropdown Menu for Type of Benefit.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years. Frequency of Benefit.

Was this a one-time benefit or is it a continuing or recurring benefit?

[] One Time

[] Recurring

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years. Benefits One-Time Occurrence.

When did you or the person you listed above receive this benefit?

[ mm/yyyy ]

[] Estimated

What is the total value of the benefit you or the person you listed above received (in U.S. dollars)?

[ Text ]

Why did you or the person you listed above receive this benefit?

[ Text ]

When did you or the person you listed above first receive this benefit?

[ mm/yyyy ]

[] Estimated

When is this benefit expected to end?

[ Text ]

How often is this benefit received?

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years. Explanation for Selection of “Other” in Dropdown Menu for Frequency of Recurring Benefits.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years. Additional Questions.

What is the total value of the benefit you or the person you listed above have received to date (in U.S. dollars)?

[ Text ]

Why are you or the person you listed above receiving this benefit?

[ Text ]

Do you or the person you listed above plan on accepting this benefit in the future?

[] Yes

[] No

Please explain.

[ Text ]

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years. Additional Details.

What country provides or provided this benefit?

[ Dropdown ]

Does this benefit obligate you or the person you listed above in any way to this foreign country?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years. Explanation for How Benefits Obligate Individual or Other Person to Foreign Country.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years. Explanation for How Benefits Do Not Obligate Individual or Other Person to Foreign Country.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years. Another Instance to Report.

Do you have another instance in which you or one of the people listed below received benefits from a foreign country in the past five years?

• Spouse or legally recognized partner from a civil marriage, civil union, domestic partnership, or common law marriage

• Person with whom you are in a committed, spouse-like relationship

• Dependent child

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like, or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years.

This question is for U.S. citizens only. If you are not a U.S. citizen go to Section 27.

*** End Of Branch ***

Are you or any of the people listed below eligible to receive benefits from a foreign country in the future?

• Spouse or legally recognized partner from a civil marriage, civil union, domestic partnership, or common law marriage

• Person with whom you are in a committed, spouse-like relationship

• Dependent child

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Future Benefits

Who is eligible to receive a future benefit? (If more than one of the people listed is eligible select one. There will be an opportunity to input multiple entries.)

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Future Benefits for Dependent Child

What is the name of the dependent child?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]	[] None

[1] Branch Auto Populate for Affirmative Answer for Future Benefit with Benefit Details

What is the future benefit? (If more than one select one. There will be an opportunity to input multiple entries.)

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Future Benefit with Other Response

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Future Benefit with Additional Benefits

When are you or the person you listed above expected to receive this future benefit?

[ mm/yyyy ]

[] Estimated

How often will you or the person you listed above receive this future benefit?

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Future Benefit with Other Frequency

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Future Benefit with Additional Benefits

What country will provide this future benefit?

[ Dropdown ]

Why are you or the person you listed above eligible to receive this future benefit?

[ Text ]

What is the total value of this future benefit (in U.S. dollars)?

[ Text ]

Do you or the person you listed above plan on accepting this benefit in the future?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Future Benefit with Plan to Accept

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Future Benefit with Obligation

Does this future benefit obligate you or the person you named in any way to this foreign country?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Future Benefit with Obligation Explanation

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Future Benefit with No Obligation Explanation

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Future Benefit with Another Instance to Report.

Do you have another instance in which you or one of the people listed below is eligible to receive benefits from a foreign country in the future?

• Spouse or legally recognized partner from a civil marriage, civil union, domestic partnership, or common law marriage

• Person with whom you are in a committed, spouse-like relationship

• Dependent child

[] Yes

[] No

*** End Of Branch ***

This question is for U.S. citizens only. If you are not a U.S. citizen go to Section 27.

For this question:

• A foreign national is any person who is not a citizen or national of the U.S.

• Financial support is any amount of monetary assistance. (This does not include one-time minor purchases (such as toiletries, a magazine, a paperback book or other small item purchases), buying a lunch or dinner, or the like.).

Have you provided financial support to a foreign national in the past five years?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Providing Financial Support to Foreign National in the Past Five Years. Name of Individual.

What is the foreign national's name?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

Does this foreign national currently live in the U.S.?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Providing Financial Support to Foreign National in the Past Five Years. Individual’s Address in the U.S.

What is their address?

[] I Don't Know

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

[] I Don't Know

City

[ Text ]

[] I Don't Know

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[] I Don't Know

Is this a U.S. military installation?		[] Yes	[] No
		[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer to Providing Financial Support to Foreign National in the Past Five Years. Individual’s Address in the U.S. Branch on a Military Installation

What is the name of the U.S. military installation?

[ Text ]

[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer to Providing Financial Support to Foreign National in the Past Five Years. Individual’s Address Not in the U.S.

Where do they live?

[] I Don't Know

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

[] I Don't Know

Country

[ Dropdown ]

Is this a U.S. military installation or U.S. diplomatic facility?		[] Yes	[] No
		[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer to Providing Financial Support to Foreign National in the Past Five Years. Individual’s Address Not in the U.S. but in U.S. Military Installation or U.S. Diplomatic Facility.

What is the name of the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] Not Applicable (Text)

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] I Don't Know

[1] Branch Auto Populate for Affirmative Answer to Providing Financial Support to Foreign National in the Past Five Years. Details.

What is your relationship to this foreign national?

[ Text ]

How often do you or did you give money to this foreign national?

[ Text ]

What is the total amount of money you've given this foreign national (in U.S. dollars)?

[ Text ]

Why do you or did you give money to this foreign national?

[ Text ]

Do you plan on giving money to this foreign national in the future?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Providing Financial Support to Foreign National in the Past Five Years. Explanation for Continuing Financial Support in Future.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Providing Financial Support to Foreign National in the Past Five Years. Explanation for No Plan to Continue Financial Support.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer to Providing Financial Support to Foreign National in the Past Five Years. Foreign National Country of Citizenship.

Provide country(ies)of citizenship for this foreign national. (Select all that apply.)

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Providing Financial Support to Foreign National in the Past Five Years. Another Instance to Report.

Do you have another instance in which you've provided financial support to a foreign national in the past five years?

[] Yes

[] No

*** End Of Branch ***

Section 27 - Foreign Business Affairs and Foreign Government Activities

This section asks for information regarding you and your immediate family members' activities with foreign-owned businesses and foreign governments. These activities could be business related, for professional endeavors, or for personal reasons.

For this section:

• An immediate family member is a spouse; legally-recognized partner from a civil union, domestic partnership, or common law marriage; parent; stepparent; sibling; half- or step-sibling; child (including adopted and foster); stepchild; guardian, or person with whom you are in a committed, spouse-like relationship.

• For purposes of this form, the term "committed, spouse-like relationship" is defined as a relationship between two people who are not in a legally-recognized marriage, union, or domestic partnership, present themselves as a couple, and live together continuously.

• Foreign means non-U.S. -- that is, outside of the 50 U.S. states, the District of Columbia, and the U.S. territories.

• A foreign-owned business is a private business or company owned or controlled by a foreign non-government entity. It may or may not be located in the U.S.

• A foreign government refers to a non-U.S. government, its agencies, and its employees or representatives. Examples of foreign government agencies include foreign embassies, consulates, military or armed forces, intelligence services, or security services.

• A foreign organization is a foreign entity that is not a foreign-owned business or part of a foreign government.

• A foreign national is any person who is not a citizen or national of the U.S.

Have you advised, supported, or consulted for any foreign-owned business or foreign organization in the past five years? (Answer “No” if your advice, support, or consultation was part of U.S. military or government business.)

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Advised, Supported, or Consulted for Foreign-owned Business or Foreign Organization in Past Five Years. Details.

What type of advice, support, or consultation do or did you provide the foreign-owned business or foreign organization?

[ Text ]

[] I Don't Know

Who did you give this advice, support, or consultation to?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix

[ Dropdown ]

What is or was this person's role in the foreign-owned business or foreign organization?

[ Text ]

What is the name of the foreign-owned business or foreign organization?

[ Text ]

What country is this foreign-owned business or foreign organization associated with?

[ Dropdown ]

When did you give this advice, support, or consultation?

From

[ mm/yyyy ]

[] Estimated

[ mm/yyyy ]

[] Estimated

[] Present

Did you receive any compensation for your advice, support, or consultation?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Advised, Supported, or Consulted for Foreign-owned Business or Foreign Organization in Past Five Years. Explanation for Type of Compensation.

What type of compensation did you receive? (Include the monetary value of this compensation in U.S. dollars, if applicable.)

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Advised, Supported, or Consulted for Foreign-owned Business or Foreign Organization in Past Five Years. Another Instance to Report.

Do you have another instance in which you advised, supported, or consulted for a foreign-owned business or foreign organization in the past five years? (Answer “No” if your advice, support, or consultation was part of U.S. military or government business.)

[] Yes

[] No

*** End Of Branch ***

Has a foreign government official asked you or any of your family members listed below for advice or to be a consultant (paid or unpaid; formally or informally) in the past five years?

• Spouse or legally-recognized partner

• Person with whom you are in a committed, spouse-like relationship

• Parent or Stepparent

• Sibling, Step-sibling, or Half-sibling

• Child (including adopted and foster) or Stepchild

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Individual or Family Members Being Asked by a Foreign Government for Advice or to be Consultant in Past Five Years. Whom.

Who was asked by a foreign government official for advice or to be a consultant (paid or unpaid; formally or informally) in the past five years? (If more than one, select one. There will be an opportunity to input multiple entries.)

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer to Individual [Only ask name for all except selection of “myself”] or Family Members Being Asked by a Foreign Government for Advice or to be Consultant in Past Five Years. Family Member Information.

What is your family member's name?

Last Name

[ Text ]

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Individual or Family Members Being Asked by a Foreign Government for Advice or to be Consultant in Past Five Years. Details.

What is the name of the foreign government official who asked you or the family member you listed above for advice or consultation?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix

[ Dropdown ]

Which foreign government is or was this foreign government official associated with?

[ Text ]

What is the name of the foreign government agency this foreign government official is or was associated with?

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Individual or Family Members Being Asked by a Foreign Government for Advice or to be Consultant in Past Five Years. Circumstances and Date.

What were the circumstances? (Include what the foreign government official wanted advice or consultation on, where they asked for it, and any other important details.)

[ Text ]

When did this foreign government official ask for this advice or consultation?

[ mm/yyyy ]

[] Estimated

[1] Branch Auto Populate for Affirmative Answer to Individual or Family Members Being Asked by a Foreign Government for Advice or to be Consultant in Past Five Years. Another Instance to Report.

Do you have another instance in which a foreign government official asked you or a family member listed below for advice or to be a consultant (paid or unpaid; formally or informally) in the past five years?

• Spouse or legally-recognized partner

• Person with whom you are in a committed, spouse-like relationship

• Parent or Stepparent

• Sibling, Step-sibling, or Half-sibling

• Child (including adopted and foster) or Stepchild

[] Yes

[] No

*** End Of Branch ***

Has a foreign national offered you a job, asked you to consider working for them, or asked you to be a business consultant in the past five years?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Job Offer from a Foreign National in the Past Five Years. Name and Information.

What is the name of the foreign national who made the offer or request?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix

[ Dropdown ]

What type of work does or did this foreign national want you to do? (Provide details about the specific job, business proposition, or consulting work.)

[ Text ]

When did this foreign national make this offer or request?

[ mm/yyyy ]

[] Estimated

[1] Branch Auto Populate for Affirmative Answer for Job Offer from a Foreign National in the Past Five Years. Location of Job Offer.

Was this offer or request made to you in the U.S.?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Job Offer from a Foreign National in the Past Five Years. Job Offer Location in the U.S. Address.

Where did this take place?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Job Offer from a Foreign National in the Past Five Years. Job Offer Location Not in the U.S. Location.

Where did this take place?

City

[ Text ]

Country

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer for Job Offer from a Foreign National in the Past Five Years. Acceptance of Job Offer Question.

Did you accept the offer or request?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Job Offer from a Foreign National in the Past Five Years. Acceptance Details.

When did you accept this offer or request?

[ mm/yyyy ]

[] Estimated

Did you perform any services or work since accepting this offer or request?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer for Job Offer from a Foreign National in the Past Five Years. Performance Dates and Compensation Information.

When did you perform these services or work for this foreign national?

From

[ mm/yyyy ]

[] Estimated

[ mm/yyyy ]

[] Estimated

[] Present

What compensation did you receive for these services or work? (If monetary, provide the amount in U.S. dollars.)

Do you have any ongoing obligations to this

foreign national?

Please explain

[ Text ]

[] Yes

[Text]

[] No

[2] Branch Auto Populate for Affirmative Answer for Job Offer from a Foreign National in the Past Five Years. Explanation for Not Accepting Offer.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Job Offer from a Foreign National in the Past Five Years. Another Instance to Report.

Do you have another instance in which a foreign national offered you a job, asked you to consider working for them, or asked you to be a business consultant in the past five years?

[] Yes

[] No

*** End Of Branch ***

Have you had any business venture with a foreign national in the past five years that you did not report above? (Examples of business ventures include owning or co-owning a business, serving as a business consultant, or providing financial support.)

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Business Venture with Foreign National in the Past Five Years Not Previously Reported. Name or Foreign National.

What is the name of the foreign national with whom you had a business venture?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix

[ Dropdown ]

Does this foreign national currently live in the U.S.?		[] Yes	[] No
		[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer to Business Venture with Foreign National in the Past Five Years Not Previously Reported. Location of Foreign National in the U.S.

Where do they live?

[] I Don't Know

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

[] I Don't Know

City

[ Text ]

[] I Don't Know

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer to Business Venture with Foreign National in the Past Five Years Not Previously Reported. Location of Foreign National Not in the U.S.

Where do they live?

[] I Don't Know

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

[] I Don't Know

Country

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Business Venture with Foreign National in the Past Five Years Not Previously Reported. Foreign National Country of Citizenship and Type of Relationship.

Provide country(ies) of citizenship for this foreign national. (Select all that apply.)

[ Dropdown ]

[] I Don’t Know

What is your relationship with this foreign national?

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer to Business Venture with Foreign National in the Past Five Years Not Previously Reported. Explanation for Selection of “Other” in Dropdown Menu for Type of Relationship.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer to Business Venture with Foreign National in the Past Five Years Not Previously Reported. Details of Business Venture with Foreign National.

What is or was this business venture? (Describe the business venture, what service does it or did it provide, and any other important details.)

[ Text ]

How long were you involved in this business venture?

From

[ mm/yyyy ]

[] Estimated

[ mm/yyyy ]

[] Estimated

[] Present

What is or was your role in this business venture?

[ Dropdown ]

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Business Venture with Foreign National in the Past Five Years Not Previously Reported. Financial Support Provided.

How much financial support (in U.S. dollars) did you provide?

[ Text ]

[] Estimated

[1] Branch Auto Populate for Affirmative Answer to Business Venture with Foreign National in the Past Five Years Not Previously Reported. Type of Compensation Received.

What type of compensation did you receive for your service? (If monetary, provide the amount in U.S. dollars.)

[ Text ]

[1] Branch Auto Populate for Affirmative Answer to Business Venture with Foreign National in the Past Five Years Not Previously Reported. Another Instance to Report.

Do you have another business venture with a foreign national in the past five years that you haven't reported above? (Examples of business ventures include owning or co-owning a business, serving as a business consultant, or providing financial support.)

[] Yes

[] No

*** End Of Branch ***

Have you or any of your immediate family members had contact with a foreign government agency or its representatives in the past five years? (Report contact regardless if it was inside or outside of the U.S. Answer “No” if the contact was for a visa application; during a routine border crossing while traveling on a U.S. passport; or, while performing official U.S. Government business or military duty.)		[] Yes	[] No
		[] I Don't Know

[1] Branch Auto Populate for Affirmative Answer for Individual or Immediate Family Member Having Contact with Foreign Government Agency or Representative in the Past Five Years. Identify Individual with Contact.

Who had contact with a foreign government agency or its representatives? (If more than one, select one. There will be an opportunity to input multiple entries.)

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Individual or Immediate Family Member Having Contact with Foreign Government Agency or Representative in the Past Five Years. Name of Family Member.

What is the name of the family member?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix

[ Dropdown ]

What country is the foreign government agency or its representatives associated with?

[ Dropdown ]

What type of foreign government agency is this?

[ Dropdown ]

Please explain. [ Text ]

[1] Branch Auto Populate for Affirmative Answer for Individual or Immediate Family Member Having Contact with Foreign Government Agency or Representative in the Past Five Years. Details

What is the name of the foreign government agency? (Do not use acronyms or abbreviations.)

[ Text ]

[] I Don't Know

Why did you or this family member have contact with this foreign government agency or its representatives?

[ Text ]

What is the name of the representative from this foreign government agency you or this family member had contact with?

[ Text ]

[] I Don't Know

Last Name	[ Text ]	[] Letter(s) Only
		[] I Don't Know

First Name	[ Text ]	[] Letter(s) Only
		[] I Don't Know

When was the last time you or this family member had contact with this foreign government agency or its representatives?

[ mm/yyyy ]

[] Estimated

Did this contact take place in the U.S.?

[] Yes

[] No

Where did this contact take place?

[] I Don't Know

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

[] I Don't Know

City

[ Text ]

[] I Don't Know

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[] I Don't Know

Where did this contact take place?

[] I Don't Know

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

[] I Don't Know

Country

[ Dropdown ]

Do you or an immediate family member have future plans to contact a foreign government agency or its representatives?

[] Yes

[] No

Do you have another instance in which you or an immediate family member had contact with a foreign government agency or its representatives in the past five years? (Report regardless if contact was inside or outside of the U.S. Answer “No” if the contact was for a visa application; during a routine border crossing while traveling on a U.S. passport; or, while performing official U.S. Government business or military duty.)

[] Yes

[] No

Please explain.

[ Text ]

*** End Of Branch ***

Have you sponsored a foreign national to the U.S. in the past five years? (For example, as a student, for work, or for permanent residence.)

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Sponsored Foreign National to the U.S. in Past Five Years. Reason for Sponsoring.

Why did you sponsor this foreign national?

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Sponsored Foreign National to the U.S. in Past Five Years. Explanation for Selection of “Other” in Reason for Sponsoring Dropdown Menu.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Sponsored Foreign National to the U.S. in Past Five Years. Name and Information of Foreign National.

What is the name of the foreign national you sponsored?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix

[ Dropdown ]

What is their date of birth?

[ mm/yyyy ]

[] Estimated

[] I Don't Know

Where was this person born?

City

[ Text ]

Country

[ Dropdown ]

Provide country(ies) of citizenship for this person. (Select all that apply.)

[ Dropdown ]

When did you sponsor this foreign national?

From

[ mm/yyyy ]

[] Estimated

[ mm/yyyy ]

[] Estimated

[] Present

Is this foreign national currently living in the U.S.?		[] Yes	[] No
		[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer for Sponsored Foreign National to the U.S. in Past Five Years. Sponsored Foreign National Lives in the U.S. Address.

Where do they live?

[] I Don't Know

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

[] I Don't Know

City

[ Text ]

[] I Don't Know

ZIP Code

[ Text ]

[] I Don't Know

Is this a U.S. military installation?		[] Yes	[] No
		[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer for Sponsored Foreign National to the U.S. in Past Five Years. Sponsored Foreign National Lives in the U.S. on Military Installation. Name of Military Installation.

What is the name of the U.S. military installation?

[ Text ]

[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer for Sponsored Foreign National to the U.S. in Past Five Years. Sponsored Foreign National Lives Outside of the U.S. City and Country.

Where do they live?

[] I Don't Know

City

[ Text ]

[] I Don't Know

Country

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer for Sponsored Foreign National to the U.S. in Past Five Years. Additional Information on Entity Facilitating Sponsorship.

Did you work with a private organization to arrange this sponsorship?

[] Yes

[] No

What is the name of this private organization that arranged the sponsorship?

[ Text ]

Is this organization located in the U.S.?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Sponsored Foreign National to the U.S. in Past Five Years. Entity Facilitating Sponsorship in the U.S. Address.

What is the address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Sponsored Foreign National to the U.S. in Past Five Years. Entity Facilitating Sponsorship Not in the U.S. City and Country.

Where are they located?

City

[ Text ]

Country

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer for Sponsored Foreign National to the U.S. in Past Five Years. Entity Facilitating Sponsorship in the U.S. Another Instance to Report.

Do you have another instance in which you sponsored a foreign national to the U.S. in the past five years? (For example, as a student, for work, or for permanent residence.)

[] Yes

[] No

*** End Of Branch ***

Have you ever held a political office in a foreign country?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Ever Held Political Office in Foreign County. Details.

What position did you hold?

[ Text ]

When did you hold this position?

From

[ mm/yyyy ]

[] Estimated

[ mm/yyyy ]

[] Estimated

[] Present

What foreign country did you hold this political office in?

[ Dropdown ]

Why did you hold political office in this foreign country?

[ Text ]

Are you currently eligible to hold political office in this foreign country?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Ever Held Political Office in Foreign County. Explanation for Current Eligibility to hold political office in Foreign Country.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Ever Held Political Office in Foreign County. Another Instance to Report.

Do you have another instance in which you held a political office in a foreign country?

[] Yes

[] No

*** End Of Branch ***

Have you ever voted in a foreign election?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Ever Voting in Foreign Election. Details.

When did you vote in this foreign election?

[ mm/yyyy ]

[] Estimated

What country was this foreign election in?

[ Dropdown ]

Why did you vote in this foreign election?

[ Text ]

Are you currently eligible to vote in a foreign country?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Ever Held Political Office in Foreign County. Explanation for Current Eligibility to Vote in Foreign Country.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Ever Held Political Office in Foreign County. Another Instance to Report.

Do you have another instance in which you voted in a foreign election?

[] Yes

[] No

*** End Of Branch ***

Section 28 - Psychological and Emotional Health

The U.S. government recognizes the importance of the psychological and emotional health of its workforce and advocates proactive involvement with mental health and related services to support the wellbeing and recovery of federal employees and others. Your truthful responses and any information derived from your responses will not be used as evidence against you in a criminal proceeding.

The following questions ask about behavioral and mental health experiences.

Mental health treatment and counseling, in and of itself, is not a reason to revoke or deny eligibility for access to classified information or for holding a sensitive position, suitability or fitness to obtain or retain Federal or contract employment, or eligibility for physical or logical access to federally controlled facilities or information systems. Seeking, undergoing, or continuing behavioral or mental health care is typically associated with good judgment.

Has a court or administrative agency ever issued an order declaring you mentally incompetent?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ever Issuing Order Declaring Individual Mentally Incompetent. Name of Court, Date and Location of Court Questions.

What is the name of the court or administrative agency declaring you mentally incompetent?

[ Text ]

When did this court or administrative agency declare you mentally incompetent?

[ mm/dd/yyyy ]

[] Estimated

Is this court or administrative agency in the U.S.?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ever Issuing Order Declaring Individual Mentally Incompetent. Location of Court or Administrative Agency in the U.S. Address Information.

What is the address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

Where is this court located?

City

[ Text ]

Country

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ever Issuing Order Declaring Individual Mentally Incompetent. Was Decision Appealed.

Did you appeal this decision to a higher court or administrative agency?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ever Issuing Order Declaring Individual Mentally Incompetent. Appeal Information.

What is the name of the court or administrative agency you appealed to?

[ Text ]

Is this appeal's court or administrative agency in the U.S.?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ever Issuing Order Declaring Individual Mentally Incompetent. Appeal’s Court or Agency Located in the U.S. Address.

What is the address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[3] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ever Issuing Order Declaring Individual Mentally Incompetent. Appeal’s Court or Agency Not Located in the U.S. City and Country.

Where is this court located?

City

[ Text ]

Country

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ever Issuing Order Declaring Individual Mentally Incompetent. Final Disposition of Appeal. Another Appeal to Report.

What was the final disposition? (that is, did the order declaring you mentally incompetent stand or did you successfully overturn it)

[ Text ]

Is there another appeal to report?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ever Issuing Order Declaring Individual Mentally Incompetent. Another Instance to Report.

Do you have another instance in which a court or administrative agency issued an order declaring you mentally incompetent to report?

[] Yes

[] No

*** End Of Branch ***

In the past five years, has a court or administrative agency ordered you to consult with a mental health professional (for example, a psychiatrist, psychologist, licensed clinical social worker, etc.)?

(An order to a military member by a superior officer is not within the scope of this question, and therefore would not require an affirmative response. An order by a military court would be within the scope of the question and would require an affirmative response.)

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ordered Individual to Consult with a Mental Health Professional. Name of Court or Agency. Date of Order.

What is the name of the court or administrative agency ordering you to consult with a mental health professional?

[ Text ]

When did this court or administrative agency order you to consult with a mental health professional?

[ mm/dd/yyyy ]

[] Estimated

Is this court or administrative agency in the U.S.?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ordered Individual to Consult with a Mental Health Professional. Court or Agency Located in the U.S.

What is the address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ordered Individual to Consult with a Mental Health Professional. Court or Agency Not Located in the U.S. City and Country.

Where is this court located?

City

[ Text ]

Country

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ordered Individual to Consult with a Mental Health Professional. Final Disposition. Appeal to Higher Court or Administrative Agency.

What was the final disposition?

[ Text ]

Did you appeal this decision to a higher court or administrative agency?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ordered Individual to Consult with a Mental Health Professional. Name of Appeal’s Court or Agency and Location.

What is the name of the court or administrative agency you appealed to?

[ Text ]

Is this appeal's court or administrative agency in the U.S.?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ordered Individual to Consult with a Mental Health Professional. Appeal’s Court or Administrative Agency Located in the U.S. Address.

What is the address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

Where is this court located?

City

[ Text ]

Country

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ordered Individual to Consult with a Mental Health Professional. Appeal’s Final Disposition Information. Any Other Appeal.

What was the final disposition? (that is, did the order to consult with a mental health professional stand or did you successfully overturn it)

[ Text ]

Is there another appeal to report?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Court or Administrative Agency Ordered Individual to Consult with a Mental Health Professional. Another Instance to Report.

Do you have another instance in which a court or administrative agency issued an order to consult with a mental health professional to report?

[] Yes

[] No

*** End Of Branch ***

In the past five years, have you been admitted to a hospital, or been required to be evaluated in a hospital for any mental health condition or behavioral emergency? Include any inpatient hospitalizations, partial hospitalizations, and emergency room visits for a mental health condition(s) or behavioral emergency.

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Hospitalization or Evaluation in a Hospital for Any Mental Health Condition or Behavioral Emergency in the Past Five Years. Details, Date and Location of Facility.

Was the hospitalization voluntary? (A No response will be considered as involuntary)

[] Yes

[] No

When did you go to the hospital?

[ mm/yyyy ]

[] Estimated

When did you leave the hospital?

[ mm/yyyy ]

[] Estimated

What was the name of the hospital?

[ Text ]

Is this hospital in the U.S.?

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Hospitalization or Evaluation in a Hospital for Any Mental Health Condition or Behavioral Emergency in the Past Five Years. Facility in the U.S. Address.

What is the address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

What is the address?

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

Country

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Hospitalization or Evaluation in a Hospital for Any Mental Health Condition or Behavioral Emergency in the Past Five Years. Another Instance to Report.

Do you, in the last five years, have another occurrence of having been admitted to a hospital, or been required to be evaluated in a hospital for any mental health condition or behavioral emergency (include any inpatient hospitalizations, partial hospitalizations, and emergency room visits for a mental health condition(s) or behavioral emergency)?

[] Yes

[] No

*** End Of Branch ***

Have you ever been diagnosed by a physician or other health professional (for example, a psychiatrist, psychologist, licensed clinical social worker, or nurse practitioner) with psychotic disorder, schizophrenia, schizoaffective disorder, delusional disorder, bipolar mood disorder, borderline personality disorder, or antisocial personality disorder?		[] Yes	[] No
		[] I Don't Know

[1] Branch Auto Populate for Affirmative Answer to Ever Having Been Diagnosed with Psychotic Disorder, Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Bipolar Mood Disorder, Borderline Personality Disorder, or Antisocial Personality Disorder. Dates, Health Care Professional Information, Location.

What are the dates of diagnosis?

From (Month/Year)

[ mm/yyyy ]

[] Estimated

To (Month Year)

[ mm/yyyy ]

[] Estimated

[] Present

If in the last five years, what is the name of the health care professional who diagnosed you, or is currently treating you for such a diagnosis, or with whom you have discussed such condition?

[ Text ]

What is the health care professional's telephone number?

[Ctry|Num|Ext]

Type [] [Day/Night/Both]

Is the address of the healthcare professional in the U.S.?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Ever Having Been Diagnosed with Psychotic Disorder, Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Bipolar Mood Disorder, Borderline Personality Disorder, or Antisocial Personality Disorder. Healthcare Professional in the U.S. Address.

What is the address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

What is the address?

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

Country

[ Dropdown ]

Is the agency, organization, or facility where counseling/treatment was provided in the last five years same as above?

[] Yes

[] No

What is the agency, organization, or facility where counseling/treatment was provided in the last five years?

[ Text ]

What is the agency, organization, or facility's telephone number?

[Ctry|Num|Ext]

Type [] [Day/Night/Both]

Is the address of the agency, organization, or facility where treatment was provided in the last five years in the U.S.?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer to Ever Having Been Diagnosed with Psychotic Disorder, Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Bipolar Mood Disorder, Borderline Personality Disorder, or Antisocial Personality Disorder. Location of Counseling/Treatment in the U.S. Address.

What is the address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

What is the address?

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

Country

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Ever Having Been Diagnosed with Psychotic Disorder, Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Bipolar Mood Disorder, Borderline Personality Disorder, or Antisocial Personality Disorder. Branch Questions for Selection of “I Don’t Know.”

Have you ever believed you had any of the following?

A. Psychotic symptoms or psychosis (i.e., hearing, seeing, feeling, or smelling things that were not real or could not be perceived by others; belief that other people are out to get you, that you are being followed, watched, or recorded; belief that you could read other people's minds or they can read yours; or belief that you have a special power).

[] Yes

[] No

B. Manic or hypomanic episodes (i.e., sustained periods of very high energy, feeling hyper, euphoric, highly distractible, or having a decreased need for sleep or not sleeping for long periods of time without feeling tired).

[] Yes

[] No

C. Impulsive behavior or behavior you felt unable to control and caused negative consequences (e.g., uncontrolled gambling, other addictive behavior, compulsive sexual behavior, etc.).

[] Yes

[] No

D. A plan to hurt or kill someone else that you either acted upon or would have acted upon if someone had not intervened.

[] Yes

[] No

In the last five years, did you seek treatment due to any of these?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer to Ever Having Been Diagnosed with Psychotic Disorder, Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Bipolar Mood Disorder, Borderline Personality Disorder, or Antisocial Personality Disorder. Selection of “I Don’t Know” but Affirmative Answer to Any of Options A, B, C, or D above. Treatment Details.

What are the treatment dates?

From (Month/Year)

[ mm/yyyy ]

[] Estimated

To (Month Year)

[ mm/yyyy ]

[] Estimated

[] Present

What is the name of the health care professional who treated you in the last five years, or is currently treating you?

[ Text ]

What is the health care professional's telephone number?

[Ctry|Num|Ext]

Type [] [Day/Night/Both]

Is the address of the healthcare professional who treated you in the last five years, or is currently treating in the U.S.?

[] Yes

[] No

[4] Branch Auto Populate for Affirmative Answer to Ever Having Been Diagnosed with Psychotic Disorder, Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Bipolar Mood Disorder, Borderline Personality Disorder, or Antisocial Personality Disorder. Selection of “I Don’t Know” but Affirmative Answer to Any of Options A, B, C, or D above. Treatment Location in the U.S. Address.

What is the address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

What is the address?

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

Country

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer to Ever Having Been Diagnosed with Psychotic Disorder, Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Bipolar Mood Disorder, Borderline Personality Disorder, or Antisocial Personality Disorder. Selection of “I Don’t Know” Another Instance of Affirmative Answer to Any of Options A, B, C, or D above to Report.

Do you have any additional episodes described in A, B, C, or D to report?

[] Yes

[] No

Do you have another instance of having been diagnosed by a physician or other health professional (for example, a psychiatrist, psychologist, licensed clinical social worker, or nurse practitioner) with psychotic disorder, schizophrenia, schizoaffective disorder, delusional disorder, bipolar mood disorder, borderline personality disorder, or antisocial personality disorder?

[] Yes

[] No

*** End Of Branch ***

Section 29 - Criminal Convictions Resulting in Sentences Over One Year

This section asks for information regarding any criminal convictions that resulted in a sentence of over one year imprisonment and in which you served at least one year of that sentence. This information is needed to determine whether you may be affected by the Bond Amendment, Public Law 110-181 of January 1, 2008, which establishes restrictions on eligibility for access to some types of information (also cited as 50 U.S.C. § 3343).

• Report information even if your record has been expunged, sealed, or otherwise stricken from the court record.

• Report convictions even if you entered a plea of nolo contendere (no contest).

• Nolle Prossed – this is a Latin phrase occasionally used by the court system which means the case against you will no longer be prosecuted or was dismissed by the prosecution.

• Do not report convictions under the Federal Controlled Substances Act for which the court issued an expungement order under the authority of 21 U.S.C. § 844 or 18 U.S.C. § 3607.

• Omit any violation of law committed before your 18th birthday if finally decided in juvenile court or appealed from juvenile court to a higher court and dismissed.

For this section:

• Domestic violence -- is a crime of violence (such as battery or assault) against your child; dependent; current or former spouse; current or former partner from a civil union, domestic partnership, or common law marriage; person you are in a committed, spouse-like relationship with; or, someone with whom you share a child in common. This includes crimes that meet this definition even if the term “domestic violence” is not specifically used in the criminal charge or conviction.

Were you ever convicted of a crime in a U.S. court where 1) you were sentenced to over one year imprisonment and 2) you served at least one year of that sentence? (U.S. courts include Federal, state, local, tribal, or military.)

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S. Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence. Conviction Reported in Another Section of this Form.

Did you report this conviction in another section of this form?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S. Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence. Conviction Not Previously Reported on this Form. Details.

Describe in detail the nature of the offense. (Include what happened, where the offense occurred, who was involved, what was the motivation, and any other details.)

[ Text ]

When did the offense happen?

[ mm/yyyy ]

[] Estimated

Was domestic violence involved?

[] Yes

[] No

Were firearms involved?

[] Yes

[] No

Were explosives involved?

[] Yes

[] No

Were drugs involved?

[] Yes

[] No

Was alcohol involved?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S. Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence. Conviction Not Previously Reported on this Form. Details on Charge(s).

What were you charged with? (If there is more than one charge for this offense, input one. There will be an opportunity to input multiple entries. You must include charges that were dismissed, disposed of, or nolle prossed.)

[ Text ]

What type of charge is this?

[ Dropdown ]

[4] Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S. Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence. Conviction Not Previously Reported on this Form. Explanation for Selection of “Other” in Dropdown Menu for Type of Charge.

Please explain.

[ Text ]

What was the outcome of this charge?

[ Dropdown ]

Please explain.

[ Text ]

[4] Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S. Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence. Another Charge to Report.

Do you have another charge for this offense to report?

[] Yes

[] No

[4] Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S. Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence. Final Outcome of Probation. Dates.

What were the dates of your probation?

From

[ mm/yyyy ]

[] Estimated

[ mm/yyyy ]

[] Estimated

[] Present

When were you convicted?

[ mm/yyyy ]

[] Estimated

What was your sentence? (Select all that apply.)

[ Dropdown ]

[5] Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S. Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence. Final Outcome of Conviction. Explanation for Selection of “Other” in Dropdown Menu for Type of Sentence.

Please explain.

[ Text ]

When were you imprisoned?

From

[ mm/yyyy ]

Were you granted parole or supervised release?

[] Yes

[] No

What were the dates of your parole or supervised release?

From

[ mm/yyyy ]

[] Estimated

[ mm/yyyy ]

[] Estimated

[] Present

[2] Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S. Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence. Another Charge.

Do you have another charge for this offense to report?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S. Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence. Case Closed Date.

What date was your case closed?

[ mm/yyyy ]

[] Estimated

[] Not Closed

[2] Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S. Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence. Court Name and Location.

What is the name of the court involved? (Do not use acronyms or abbreviations.)

[ Text ]

Is this court in the U.S.?

[3] Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S. Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence. Explanation Why Case is Not Closed.

Please explain.

[ Text ]

[3] Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S. Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence. Court Location in the U.S. Address.

What is the address of this court?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

Where is this court located?

City

[ Text ]

Country

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S. Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence. Another Instance to Report.

Do you have another instance in which you were convicted of a crime in a U.S. court where 1) you were sentenced to over one year imprisonment and 2) you served at least one year of that sentence? (U.S. courts include Federal, state, local, tribal, or military.)

[] Yes

[] No

*** End Of Branch ***

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Author	Loss, Lisa M
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File Created	2024-07-19